Medically Necessary and Appropriate Clause Samples
The 'Medically Necessary and Appropriate' clause defines the criteria under which medical services, treatments, or supplies are covered by an insurance policy or health plan. It typically requires that any care provided must be essential for the diagnosis or treatment of a medical condition and must meet accepted standards of medical practice. For example, a procedure may only be reimbursed if it is not experimental and is considered standard care for the patient's condition. This clause ensures that coverage is limited to treatments that are justified by medical need, thereby preventing unnecessary or excessive healthcare costs and promoting responsible use of healthcare resources.
Medically Necessary and Appropriate. “Medically Necessary and Appropriate” means that the benefits under this Agreement for services received from a Network provider will be provided only when and so long as such services are determined by the Plan or its designated agent to be: 1) appropriate for the symptoms and diagnosis or treatment of the member’s condition, illness, disease or injury; and 2) provided for the diagnosis, of the direct care and treatment of the member’s condition, illness, disease or injury; and 3) in accordance with standards of good medical practice; and 4) not primarily for the convenience of the member, or the member’s physician and/or other provider; and 5) the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as a bed patient due to the nature of the services rendered or the member’s condition, and the member cannot receive safe or adequate care as an outpatient. Network facility providers, Highmark managed care facility providers, network professional providers and PremierBlue Shield professional providers (out-of-area) will accept this determination of medical necessity. Out-of-network providers may not accept this determination and may ▇▇▇▇ the member for services determined not to be Medically Necessary and Appropriate. See the Agreement for further explanation.
Medically Necessary and Appropriate. “Medically necessary and appropriate” means that the benefits under the Agreement for services received from a network provider will be provided only when and so long as such services are determined by the Plan to be: a) appropriate for the symptoms and diagnosis or treatment of the member’s condition, illness, disease or injury; and b) provided for the diagnosis, or the direct care and treatment of the member’s condition, illness, disease or injury; and c) in accordance with standards of good medical practice; and d) not primarily for the convenience of the member, or the member’s physician and/or other provider; and e) the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an inpatient due to the nature of the services rendered or the member’s condition, and the member cannot receive safe or adequate care as an outpatient. Network facility providers and preferred professional providers will accept this determination of medical necessity. Out-of-network providers are not obligated to accept this determination and may ▇▇▇▇ the member for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.
Medically Necessary and Appropriate. “Medically Necessary and Appropriate” means services or supplies that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a) in accordance with generally accepted standards of medical practice; and b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. Benefits under the Agreement for services or supplies will be provided only when the Plan or its designated agent, utilizing the criteria set forth in the paragraph above, determines that such service or supply is medically necessary and appropriate. Network facility providers and preferred professional providers will accept this determination of medical necessity. Out-of-Network providers are not obligated to accept this determination and may bill the member for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.
Medically Necessary and Appropriate. The services or supplies described in the Agreement are covered only when they are Medically Necessary and Appropriate. The determination of Medical Necessity and Appropriateness is made by the member’s PCP, the network specialist and/or KHPW, or its designated agent. Any covered services requested by a member which are not Medically Necessary and Appropriate will not be covered. The member’s receipt of a preauthorization from KHPW, or its designated agent, to receive services from a provider outside the network shall constitute proof of Medical Necessity and Appropriateness for purposes of determining a member’s potential liability for covered services. Medically Necessary and Appropriate is defined as follows: Services or supplies provided by a provider that the PCP, network specialist and/or KHPW, or its designated agent, determine are:
a. appropriate for the symptoms and diagnosis or treatment of the member's condition, illness, disease or injury; and
b. provided for the diagnosis, or the direct care and treatment of the member's condition, illness, disease or injury; and
c. in accordance with standards of good medical practice; and
d. not primarily for the convenience of the member or the member's provider; and
e. the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an inpatient due to the nature of the services rendered or the member's condition, and the member cannot receive safe or adequate care in some other setting without adversely affecting the member’s condition or quality of medical care. No benefits will be provided hereunder unless it is determined that the service or supply is Medically Necessary and Appropriate.
Medically Necessary and Appropriate. “Medically Necessary and Appropriate” means that the benefits under this Agreement for services received from a participating provider will be provided only when and so long as such services are determined by the Plan or its designated agent to be: 1) appropriate for the symptoms and diagnosis or treatment of the subscriber’s condition, illness, disease or injury; and 2) provided for the diagnosis, of the direct care and treatment of the subscriber’s condition, illness, disease or injury; and 3) in accordance with standards of good medical practice; and 4) not primarily for the convenience of the subscriber, or the subscriber’s physician and/or other provider; and 5) the most appropriate supply or level of service that can safely be provided to the subscriber. When applied to hospitalization, this further means that the subscriber requires acute care as a bed patient due to the nature of the services rendered or the subscriber’s condition, and the subscriber cannot receive safe or adequate care as an outpatient. Participating hospitals, facility other providers and professional providers will accept this determination of medical necessity. Non-participating providers are not obligated to accept this determination and may bill the subscriber for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.